1. Treating the Uninsured: Provider Perspectives on Caring for Uninsured Patients
Karen Michael, RN, MSN, MBA
Vice President of Clinical Services
AmeriHealth Mercy

2. Who We Are Mission-driven, provider-affiliated
Largest Medicaid-only, multi-state plan with over 20 years of experience
Four distinct product lines:
Full risk health plans
Management and administrative service contracts
PerformRx pharmacy management
PerforMED care management 2

3. AmeriHealth Mercy Family of Companies Current Markets
Contra Costa
68,822
Touchstone
3,285
Neighborhood Health Plan of Rhode Island
73,362
MDwise Hoosier Alliance
140,999
MDwise
142,544
Passport
TANF, SSI, CHIP
144,926
AmeriHealth Mercy Keystone Mercy
TANF & SSI
365,067
Horizon NJ Health
322,544
Virginia Premier 110,074
CalOptima
36,972
Inland Empire
308,800
Select Health
TANF & SSI
75,707
Optimum Health Plan
757
METCARE Health Plans
5,368
Pediatric Associates Health Plan 9,686
Membership numbers as of April 2007
Full Risk and PerformRx
MSA and PerformRx
ASA
PerformRx – Medicare Part D only
PerformRx – Medicaid only
Total Membership
Risk ,773
MSA/ASA/TPA ,156
Pharmacy-Medicaid ,149,578
PDP/Medicare Advantage ,811_
Total ,303,318

4. The Question
How can care for the uninsured be improved within today’s delivery systems?
Appropriate distribution across care settings
Improved management of chronic illnesses
Better health outcomes
Less costly

5. Similarities to Medicaid
Demographics
Geographic Distribution
Pent-up Demand
Language Barriers
Inconsistent Eligibility
Transportation
Parallel population to Medicaid – in some ways more challenging
Cluster in cities/scattered in rural areas
On and off MA roles (30% of 17,000)
Children in household may have MA coverage –
Parental influence may hinder child’s access to coverage
Children more likely to use health care if parents did/uninsured children twice as likely to see doctor if parent visited doctor/insured children three times as likely
Uninsured adults more likely to have neg. experience – role model this orientation to their children

6. Service Utilization System Navigation/Care Coordination
No Medical Home/PCP
No access to advocate who knows the system
Source: National Public Engagement Campaign on Chronic Illness – Physician Survey, conducted by Mathematica Policy Research Inc., 2001.

7. Service Utilization
40% of Emergency Room visits have Primary Care components and/or relate to chronic illness
Two patterns:
Use of ER for primary care – or unmanaged chronic care
Visit to the ER results in admission
Hospitalizations are emergent – These individuals will be admitted (complex medical problems, no treatment history)
Source: Emergency Room Data – 17,000 Uninsured individuals; CY 2006

8. The Setting 2 urban community hospitals Demographically challenged
Forecasted population decreases
Primarily medical admissions
70-75% of patients from Government payors
Diminishing physician availability
M Fitz: 368-bed acute care, community teaching hospital serving Delaware County and Southwest Philadelphia (70 years)
M Hosp: full-service 266-bed community hospital (88 years)
-   
    -    Demographically challenged with forecasted population decreases
    -    Primarily Medical Admissions, High Surgery out migration from the service area to Academic Medical Center Providers
    -    High utilizers of Emergency services for all levels of care - primary, Urgent, emergent % of admissions from ED
    -    70-75% of patients from Government payors (Medicare & Medicaid)    -   
    -    Levels of medical and administrative non-compliance to regarding healthy lifestyles and potentially available health coverage (but I guess you already know this)
    -    Little to no new physicians entering service area to practice
    -    Specialty Physicians leaving service area and not available patients, for ER coverage or any other call
    -    Lingering Malpractice issues/perceptions
    -    Placement issues, readmissions, Care Management, integration/coordination with other level providers

9. Community Need Index Five Counties
Communities of high Need - we call this the red zone based on the Solucient Community Need Index - See Map and the Claritas Health Status Index

10. Uninsured: Higher Levels of Chronic Conditions
Especially High Blood Pressure and Diabetes
Data is from Mercy Fitzgerald Analysis
Source: Community Needs Assessment, National Research Corporation, Survey

11. The PerforMED Model Predictive Modeling Holistic Approach
Barrier Resolution
Advocacy
Community Outreach
Data Management
Remembering Maslow – “DM” story
Proactive outreach – aggressive
P4P incentives – new member assessment
Create medical record from hospital and clinic data
Health literacy, language, transportation
Access – providers, community services
Rapid response team

12. The Marriage Coordinate care for uninsured patients using
Inpatient and ER services
Goals:
Improve quality of care
Move care from IP to OP settings

13. Challenges Network Confidentiality statutes Medications Facilities
Primary Care
Specialty Care
Ancillary Services
Confidentiality statutes
Medications

14. Discussion